,i  #aac? ,,congress  #b;d ,session  ,h4
 ,r4 #dgfb  ,,9 ,,! ,,h\se ,,(          
,,repres5tatives  ,may #bi1 #bjad ,mr4  
,blum5au] 7= himself & ,mr4 ,petri7     
introduc$ ! foll[+ bill2 :i* 0 ref]r$ to
 ! ,committee on ,en]gy & ,comm]ce1 & 9 
addition to ! ,committee on ,ways &     
,means1 = a p]iod to be subsequ5tly     
det]m9$ by ! ,speak]1 9 ea* case =      
consid]ation ( su* provisions z fall )9 
! jurisdiction ( ! committee conc]n$  ,a
 ,,bill  ,to am5d title ,,xviii ( !     
,social ,security ,act to cov]          
transitional c>e s]vices to improve !   
quality & co/ effectiv5ess ( c>e "u !   
,m$ic>e ,program4  #a4 ,%ort title ,?is 
,act may be cit$ z ! ,m$ic>e            
,transitional ,c>e ,act ( #bjad4  #b4   
,f9d+s ,congress f9ds ! foll[+3  7#a7   
,!re are a numb] ( c>e models t are     
design$ to enhance coord9ation dur+     
transitions f c>e sett+s4  7#b7 ,^! c>e 
models & o!rs h demon/rat$ t effective  
c>e transitions lead to improvem5ts 9   
ov]all heal? c>e quality & result 9     

sav+s to pati5ts & ! ,unit$ ,/ates heal?
 c>e sy/em4  #c4 ,m$ic>e cov]age (      
transitional c>e s]vices  7a7 ,cov]age  
,section #ahfa ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciex7 is am5d$--  
7#a7 9 subsection 7s77#b7--  7,a7 by    
/rik+ & at ! end ( subp>agraph 7,,ee72  
7,b7 by add+ & at ! end ( subp>agraph   
7,,ff72 &  7,c7 by ins]t+ aft]          
subp>agraph 7,,ff7 ! foll[+ new         
subp>agraph3  7,,gg7 transitional c>e   
s]vices 7z def9$ 9 subsection           
7iii77#a772  2 &  7#b7 by add+ at ! end 
! foll[+ new subsection3  7iii7         
,transitional c>e s]vices  7#a7 ,! t]m  
transitional c>e s]vices means s]vices  
describ$ 9 p>agraph 7#b7 furni%$ to a   
qualifi$ individual 7describ$ 9 p>agraph
 7#c77 by a transitional c>e cl9ician 7z
 def9$ 9 p>agraph 7#d77 act+ z an       
employee ( 7or pursuant to a contract )7
 a qualifi$ transitional c>e entity 7z  
def9$ 9 p>agraph 7#e77 dur+ !           
transitional c>e p]iod 7z def9$ 9       
p>agraph 7#f77 = ! qualifi$ individual4 

7#b7 ,! s]vices describ$ 9 ?is p>agraph 
are s]vices t support a qualifi$        
individual dur+ ! transitional c>e p]iod
 & include ! foll[+3  7,a7 ,a           
compreh5sive assessm5t ( ! individual   
prior to ! individual's transition f "o 
c>e facility to ano!r c>e facility or   
home1 includ+ an assessm5t ( !          
individual's physical & m5tal condition1
 cognitive & functional capacities1     
m$ication regim5 & adh]5ce1 social &    
environm5tal ne$s1 & prim>y c>egiv] ne$s
 & res\rces4  7,b7 ,developm5t ( a      
compreh5sive1 evid5c$-bas$ plan ( c>e = 
! individual develop$ ) ! individual & !
 individual's prim>y c>egiv] & o!r heal?
 team memb]s1 id5tify+ pot5tial heal?   
risks1 treatm5t goals1 curr5t !rapies1 &
 future s]vices = bo? ! individual & any
 prim>y c>egiv]4  7,c7 ,developm5t ( a  
compreh5sive m$ications managem5t plan t
 ensures ! safe use ( m$ications & is   
bas$ on ! individual's plan ( c>e4 ,su* 
managem5t plan %all include ! foll[+3   
7i7 ,id5tification ( individual's       

m$ications 9 use 7includ+ prescription &
 non-prescription m$ications74  7ii7    
,assessm5t & 7if ne$$7 consultation )   
key m$ical provid]s to ensure m$ications
 are necess>y1 appropriate1 & free (    
discrepancies4  7iii7 ,assessm5t ( !    
individual & family c>egiv]'s heal?     
lit]acy reg>d+ ! ability to prop]ly     
foll[ m$ication in/ructions4  7iv7      
,individual & family education & c\nsel+
 ab\t m$ications4  7v7 ,tea*+ & c\nsel+ 
! individual & ! individual's prim>y    
c>egiv] 7z appropriate7 to assure       
adh]5ce to m$ications & o!r !rapies &   
avoid adv]se ev5ts4  7,d7 ,implem5tation
 ( a plan to facilitate ! safe          
transition ( ! individual f "o level (  
c>e1 c>e sett+1 or provid] to ano!r1 :i*
 transition plan %all include at lea/ ! 
foll[+3  7i7 ,a process to address !    
individual's symptoms4  7ii7 ,an        
e/abli%$ process = ! individual & family
 c>egiv]s to receive timely access to   
key heal? c>e provid]s dur+ an episode (
 c>e z requir$ by ! individual's        

condition4  7iii7 ,an e/abli%$ process =
 communicat+ ) ! individual1 family     
c>egiv]s1 & o!r heal? c>e provid]s      
po/transition f an episode ( c>e4  7iv7 
,a sy/em t ensures own]%ip1             
responsibility1 & acc\ntability = ! c>e 
( ! individual at all times1 includ+    
id5tify+ & docum5t+ any family c>egiv]  
7or c>egiv]s7 t exi/4  7v7 ,provid+     
in=mation & res\rces ab\t condition &   
c>e *oices to adequately prep>e !       
individual & c>egiv]s = in=m$           
decisionmak+4  7,e7 ,provid+ to !       
qualifi$ individual1 prim>y c>egiv]1 &  
appropriate cl9icians & ! qualifi$      
transitional c>e entity provid+ ongo+   
c>e at ! conclusion ( ! transitional c>e
 p]iod1 a writt5 summ>y t includes !    
goals e/abli%$ 9 ! plan ( c>e describ$ 9
 subp>agraph 7,b71 progress 9 a*iev+ su*
 goals1 & rema9+ treatm5t ne$s4  7,f7   
,o!r s]vices t ! ,secret>y det]m9es are 
appropriate4  ,! ,secret>y %all det]m9e 
& update f "t to "t ! s]vices to be     
includ$ 9 transitional c>e s]vices z    

appropriate1 bas$ on ! evid5ce ( _!     
effectiv5ess 9 r$uc+ hospital           
readmissions & improv+ heal? outcomes4  
7#c7  7,a7 ,9 ?is subsection1 subject to
 subp>agraph 7,c71 ! t]m qualifi$       
individual means an individual :o--  7i7
 has be5 admitt$ to a subsection 7d7    
hospital 7z def9$ = purposes ( section  
#ahhf7 = inpati5t hospital s]vices or to
 a critical c>e hospital = inpati5t     
critical access hospital s]vices2 &     
7ii7 is id5tifi$ by ! ,secret>y z be+ at
 highe/ risk = readmission or = a poor  
transition f su* a hospital to a        
po/hospital site ( c>e4  7,b7 ,!        
id5tification "u subp>agraph 7,a77ii7   
%all be bas$ on a*iev+ a m9imum         
hi]>*ical condition category score      
7specifi$ by ! ,secret>y7 9 ord] to     
t>get eligibility b5efits "u ?is        
subsection to individuals ) multiple    
*ronic conditions & o!r risk factors1   
su* z cognitive impairm5t1 depression1  
or a hi/ory ( multiple hospitalizations4
  7,c7 ,aft] submitt+ to ,congress !    

evaluation "u section #b7;d7 ( ! ,m$ic>e
 ,transitional ,c>e ,act ( #bjad &      
consid]+ any co/ sav+s & quality        
improvem5ts f ! prior implem5tation (   
transitional c>e s]vices "u ?is title1 !
 ,secret>y may exp& eligibility (       
qualifi$ individuals to include         
mod]ate-risk & l[]-risk individuals1 z  
det]m9$ 9 accordance ) eligibility      
crit]ia specifi$ by ! ,secret>y4 ,9     
exp&+ eligibility1 ! ,secret>y may      
modify or scale transitional c>e s]vices
 to meet ! specific ne$s ( mod]ate-risk 
& l[]-risk individuals4  7,d7 ,!        
,secret>y %all ensure t qualifi$        
individuals receiv+ transitional c>e    
s]vices are n receiv+ duplicative       
s]vices "u ?is title4  7#d7  7,a7 ,! t]m
 transitional c>e cl9ician means1 )     
respect to a qualifi$ individual1 a     
nurse1 case manag]1 social work]1       
physician assi/ant1 physician1 ph>maci/1
 or o!r lic5s$ heal? pr(essional :o--   
7i7 has receiv$ specializ$ tra9+ 9 !    
cl9ical c>e ( p ) multiple *ronic       

conditions 7includ+ m$ication managem5t7
 & communication & coord9ation )        
multiple provid]s ( s]vices1 suppli]s1  
pati5ts1 & _! prim>y c>egiv]s2  7ii7 is 
support$ by an int]discipl9>y team 9 a  
mann] t assures cont9uity ( c>e ?r\gh\t 
a transitional c>e p]iod & across c>e   
sett+s 7includ+ ! resid5ces ( qualifi$  
individuals72  7iii7 is employ$ by 7or  
has a contract )7 a qualifi$            
transitional c>e entity = ! furni%+ (   
transitional c>e s]vices2 &  7iv7 meets 
su* p>ticipation crit]ia z ! ,secret>y  
may specify consi/5t ) ?is subsection4  
7,b7 ,9 e/abli%+ p>ticipation crit]ia "u
 subp>agraph 7,a77iv71 ! ,secret>y %all 
assure t transitional c>e cl9icians meet
 relevant scope ( practice & tra9+      
requirem5ts & h ! ability to meet !     
individual ne$s ( qualifi$ individuals4 
7#e7 ,! t]m qualifi$ transitional c>e   
entity means--  7,a7 a hospital or a    
critical c>e hospital2  7,b7 a home     
heal? ag5cy2  7,c7 a prim>y c>e         
practice2  7,d7 a f$]ally qualifi$ heal?

 c5t] or rural heal? cl9ic2  7,e7 a     
long-t]m c>e facility2  7,f7 a m$ical   
home2  7,g7 an appropriate              
community-bas$ organization describ$ 9  
section #cjbf7;b77#a77;,b7 ( ! ,pati5t  
,protection & ,af=dable ,c>e ,act 7#db  
,u4,s4,c4 #acie;b-#a note72  7,h7 an    
assi/$ liv+ c5t]2  7,i7 an acc\ntable   
c>e organization2 &  7,j7 ano!r entity  
approv$ by ! ,secret>y = purposes ( ?is 
subsection4  7#f7 ,! t]m transitional   
c>e p]iod means1 ) respect to a qualifi$
 individual1 ! p]iod--  7,a7 beg9n+ on !
 date ! individual is admitt$ to a      
subsection 7d7 hospital 7z def9$ =      
purposes ( section #ahhf7 = inpati5t    
hospital s]vices or is admitt$ to a     
critical c>e hospital = inpati5t        
critical access hospital s]vices1 = :i* 
paym5t may be made "u ?is title2 &  7,b7
 end+ on ! la/ day ( ! #de-;day p]iod   
beg9n+ on ! date ( ! individual's       
dis*>ge f su* hospital or critical c>e  
hospital4  4  7b7 ,paym5t & p]=mance    
measures ,section #ahcc ( ! ,social     

,security ,act 7#db ,u4,s4,c4 #aciel7 is
 am5d$--  7#a7 9 subsection 7a77#a71 by 
/rik+ & be=e 7,z7 & by ins]t+ be=e !    
semicolon at ! end ! foll[+3 1 & 7,,aa7 
) respect to transitional c>e s]vices 7z
 def9$ 9 section #ahfa7;iii77#a771 !    
am\nts paid %all be #ajj p]c5t ( ! am\nt
 det]m9$ "u subsection 7z72  7#b7 9 !   
fir/ s5t5ce ( subsection 7b71 by ins]t+ 
or transitional c>e s]vices 7z def9$ 9  
section #ahfa7;iii77#a77 aft] 7z def9$ 9
 section #ahfa7;hh77#a772 &  7#c7 by    
add+ at ! end ! foll[+ new subsection3  
7z7 ,paym5t & p]=mance measures =       
transitional c>e s]vices  7#a7 ,paym5t  
7,a7 ,9 g5]al ,! ,secret>y %all det]m9e 
! me?od ( paym5t = transitional c>e     
s]vices "u ?is "p1 includ+ appropriate  
risk adju/m5t t reflects ! diff]5ces 9  
res\rces ne$$ to provide transitional   
c>e s]vices to individuals ) diff]+     
*>act]i/ics & circum/ances &1 :5        
applicable1 ! p]=mance measures "u      
p>agraph 7#c74 ,! paym5t am\nt %all be  
suffici5t to ensure ! provision (       

necess>y transitional c>e s]vices       
?r\gh\t ! transitional c>e p]iod4 ,!    
paym5t %all be /ructur$ 9 a mann] to    
explicitly recognize transitional c>e z 
an episode ( s]vices t crosses multiple 
c>e sett+s1 provid]s ( s]vices1 &       
suppli]s4 ,! paym5t ) respect to        
transitional c>e s]vices furni%$ by a   
transitional c>e cl9ician %all be made1 
not)/&+ any o!r provision ( ?is title1  
to ! qualifi$ transitional c>e entity   
:i* employs1 or has a contract )1 !     
cl9ician = ! furni%+ ( su* s]vices4     
7,b7 ,,hit inc5tive paym5t ,! ,secret>y 
may provide = an additional paym5t )    
respect to transitional c>e s]vices to  
enc\rage transitional c>e cl9icians &   
qualifi$ transitional c>e entities to   
use heal? in=mation te*nology 9 !       
provision ( su* s]vices4  7,c7 ,no      
paym5t = requir$ dis*>ge plann+ s]vices 
,paym5t %all n be made = transitional   
c>e s]vices "u ?is subsection = an      
entity ins(> z su* s]vices are o!rwise  
requir$ to be provid$ ?r\gh ! dis*>ge   

plann+ process "u section #ahfa7;ee7 or 
"u conditions ( p>ticipation = ! entity 
"u section #ahff4  7#b7 ,p]=mance       
measures  7,a7 ,acc\ntability  7i7 ,9   
g5]al ,! ,secret>y %all e/abli% a me?od 
:]eby qualifi$ transitional c>e entities
 responsible = furni%+ transitional c>e 
s]vices are held acc\ntable = process & 
outcome bas$ on p]=mance measures       
specifi$ by ! ,secret>y f ^? t h be5    
endors$ by ! ,national ,quality ,=um or 
simil> /&>d-sett+ organization or are   
o!rwise us$ 9 o!r quality programs "u   
?is title or title ,,xix4  7ii7         
,developm5t & endorsem5t ( p]=mance     
measure set ,= purposes ( c>ry+ out     
clause 7i71 ! ,secret>y %all ent] into  
an arrangem5t--  7,i7 ) ! ,national     
,quality ,=um = ! evaluation1           
endorsem5t1 & recomm5dation ( additional
 p]=mance measures = transitional c>e   
s]vices & to id5tify rema9+ gaps 9      
available measures1 includ+ measures to 
bo? ! s5d+ & receiv+ side ( !           
transition2 &  7,,ii7 ) ! ,ag5cy =      

,heal?c>e ,rese>* & ,quality to support 
measure developm5t1 to fill gaps 9      
available measures1 to conduct          
comp>ative effectiv5ess rese>* (        
transitional c>e models & tools1 & to   
provide = ! ongo+ ma9t5ance ( ! set (   
p]=mance measures = transitional c>e    
s]vices4  7,b7 ,pay = p]=mance ,z soon z
 practicable aft] reliable process &    
outcome p]=mance measures h be5 endors$ 
& specifi$ "u subp>agraph 7,a71 !       
,secret>y %all provide t ! paym5t am\nts
 "u p>agraph 7#a7 = transitional c>e    
s]vices %all be l9k$ to p]=mance on su* 
measures4  7,c7 ,public report+ ,!      
,secret>y %all e/abli% a me*anism to    
publicly report on a qualify+           
transitional c>e entity's p]=mance on   
su* measures1 includ+ provid+ b5*m>ks to
 id5tify high p]=m]s & ^? practices t   
contribute to l[] hospital readmission  
rates4  7,d7 ,dissem9ation ( in=mation  
on be/ practices ,! ,secret>y %all      
dissem9ate in=mation on be/ practices   
us$ by transitional c>e cl9icians &     

qualifi$ transitional c>e entities 9    
furni%+ transitional c>e s]vices =      
purposes ( application 9 o!r sett+s1 su*
 z 9 conditions ( p>ticipation "u ?is   
title1 "u ! ,quality ,improvem5t        
,organization ,program "u "p ,b ( title 
,,xi1 & public-private quality          
alliances1 su* z ! ,hospital ,quality   
,alliance4  7#c7 ,prev5tion (           
inappropriate /e]+ ,! ,secret>y %all    
promulgate su* regulations z ! ,secret>y
 deems necess>y to address any          
protections ne$$1 beyond ^? o!rwise     
provid$ "u law & regulations1 to prev5t 
inappropriate /e]+ ( qualifi$           
individuals to provid]s ( s]vices1      
suppli]s1 qualifi$ transitional c>e     
entities1 or transitional c>e cl9icians1
 "u ?is "p or inappropriate limitations 
on access to ne$$ transitional c>e      
s]vices "u ?is "p4  4  7c7 ,coord9ation 
) hospital dis*>ge plann+ ,section      
#ahfa7;ee77#b7 ( ! ,social ,security    
,act 7#db ,u4,s4,c4 #aciex7ee77#b77 is  
am5d$ by add+ at ! end ! foll[+3  7,i7  

,9 ! case ( subsection 7d7 hospitals &  
critical c>e hospitals1 ! hospital mu/--
  7i7 id5tify1 z soon z practicable aft]
 admission1 ^? pati5ts :o are qualifi$  
individuals describ$ 9 p>agraph 7#c7 (  
section #ahfa7;iii72 &  7ii7 provide to 
su* pati5ts & _! prim>y c>egiv]s a li/ (
 transitional c>e entities available "u 
su* section to arrange = ! provision (  
transitional c>e s]vices1 a li/ (       
transitional c>e s]vices provid$ "u ?is 
"p1 & a notice t ! transitional c>e     
s]vice b5efit "u su* section is provid$ 
to qualifi$ individuals ) no d$uctible  
or co/ %>+4  ,no?+ 9 subp>agraph 7,i7   
%all be con/ru$ z prev5t+ a hospital or 
critical c>e hospital f ent]+ into an   
agreem5t ) a qualifi$ transitional c>e  
entity or a transitional c>e cl9ician = 
! furni%+ ( transitional c>e s]vices to 
! hospital's pati5ts4  4  7d7           
,evaluation2 report  7#a7 ,9 g5]al ,!   
,secret>y ( ,heal? & ,human ,s]vices    
%all evaluate ! p]=mance ( !            
transitional c>e b5efit "u ! am5dm5ts   

made by ?is section by measur+ ! foll[+1
 bo? = individuals receiv+ transitional 
c>e s]vices & = individuals n receiv+   
su* s]vices3  7,a7 ,admission rates to  
heal? c>e facilities4  7,b7 ,hospital   
readmission rates4  7,c7 ,co/ (         
transitional c>e & all o!r heal? c>e    
s]vices4  7,d7 ,quality ( transitional  
c>e exp]i5ces4  7,e7 ,measures ( quality
 & effici5cy4  7,f7 ,b5efici>y exp]i5ce4
  7,g7 ,heal? outcomes4  7,h7 ,r$uctions
 9 exp5ditures "u ?is title ov] "t4     
7#b7 ,report ,! ,secret>y %all submit a 
report to ,congress no lat] ?an ,april  
#a1 #bjah1 on ! p]=mance measures a*iev$
 by ! transitional c>e b5efit 9 ! fir/  
#b ye>s ( implem5tation4 ,aft] submitt+ 
su* report1 ! ,secret>y may exp& !      
b5efit to mod]ate-risk & l[]-risk       
individuals "u section                  
#ahfa7;iii77#c77;,b7 ( ! ,social        
,security ,act1 z add$ by subsection    
7a74  7e7 ,effective date ,! am5dm5ts   
made by ?is section %all apply to       
s]vices furni%$ on or aft] ,janu>y #a1  

#bjae4